Gestational Age-Specific Markers Associated with Postnatal Intervention in Fetal Suspicion of Coarctation of the Aorta.

OBJECTIVE: Fetal diagnosis of coarctation of the aorta (CoA) is currently associated with a high false-positive rate. Many predictive markers may be gestational age (GA)-specific. We sought to establish GA-specific traditional and speckle-tracking fetal echocardiography (STE) markers predictive of true CoA in neonates with prenatal suspicion. STUDY DESIGN: This is a retrospective case-control study. We compared the fetal ventricular and arch dimensions, as well as the deformation parameters by STE, of infants who required a postnatal intervention for their CoA with those who did not. Cohort was stratified based on GA before or after 30 weeks. Data extractors were masked to the outcome. The first fetal echocardiogram available was used. RESULTS: Seventy-five newborns with a fetal echocardiography performed between October 2013 and May 2022 for an antenatal suspicion of CoA were included, of which 59 (79%) had an aortic arch with nonsignificant obstruction upon ductal closure, and 16 (21%) underwent a neonatal intervention for a confirmed CoA. Before 30 weeks' GA, the right ventricular to left ventricular (RV/LV) end-diastolic width and end-diastolic area (EDA) ratios were most associated with postnatal CoA confirmation (area under the curve [AUCs] = 0.96 and 0.92). After 30 weeks' GA, the RV/LV end-diastolic width ratio (AUC = 0.95), the Z-score for the ascending aorta (AUC = 0.93), and the LV end-diastolic width Z-score (AUC = 0.91) performed the best. A decreased RV peak longitudinal strain was observed in those who developed true CoA and performed well by receiver operating characteristic analysis after 30 weeks (AUC = 0.85). In the overall cohort, the RV/LV EDA ratio was the most sensitive predictor of CoA and identified all cases with CoA. Indeed, a cutoff > 1.24 had a specificity of 69.5% and a sensitivity of 100% (receiver operating characteristic curve with an AUC of 0.88). CONCLUSION: We outlined sensitive and specific fetal markers associated with postnatal CoA based on GA at suspicion. KEY POINTS: · Fetal ventricular disproportion predicts postnatal coarctation.. · A decreased right ventircular contraction was observed in those with coarctation.. · Fetal markers differ based on gestational age at fetal evaluation..

Early cardiac function and death, severe bronchopulmonary dysplasia and pulmonary hypertension in extremely preterm infants.

BACKGROUND: Association between early cardiac function and neonatal outcomes are scarcely reported. The aim of the current study was to describe this association with death, severe bronchopulmonary dysplasia (BPD) and BPD-related pulmonary hypertension (PH). METHODS: Retrospective cohort study of infants <29 weeks born between 2015 and 2019. Infants with clinically acquired echocardiography at ≤21 days after birth were included and data were extracted by an expert masked to outcomes. RESULTS: A total of 176 infants were included. Echocardiogram was performed at a median of 9 days (IQR 5-13.5). Of these, 31 (18%) had death/severe BPD and 59 (33.5%) had death/BPD-related PH. Infants with death/severe BPD were of lower birth weight (745 [227] vs 852 [211] grams, p = 0.01) and more exposed to invasive ventilation, late-onset sepsis, inotropes and/or postnatal steroids. Early echocardiograms demonstrated decreased right ventricular [Tricuspid Annular Plane Systolic Excursion: 5.2 (1.4) vs 6.2 (1.5) cm, p = 0.03] and left ventricular function [Ejection fraction 53 (14) vs 58 (10) %, p = 0.03]. Infants with death/BPD-related PH had an increased Eccentricity index (1.35 [0.20] vs 1.26 [0.19], p = 0.02), and flat/bowing septum (19/54 [35%] vs 20/109 [18%], p = 0.021). CONCLUSIONS: In extremely premature infants, altered ventricular function and increased pulmonary pressure indices within the first 21 days after birth, were associated with the combined outcome of death/severe BPD and death/BPD-related PH. IMPACT: Decreased cardiac function on echocardiography performed during first three weeks of life is associated with severe bronchopulmonary dysplasia in extremely premature infants. In extreme preterm infants, echocardiographic signs of pulmonary hypertension in early life are associated with later BPD-related pulmonary hypertension close to 36 weeks post-menstrual age. Early cardiac markers should be further studied as potential intervention targets in this population. Our study is adding comprehensive analysis of echocardiographic data in infants born below 29 weeks gestational age.

Association of Gestational Age at Birth With Left Cardiac Dimensions at Near-Term Corrected Age Among Extremely Preterm Infants.

BACKGROUND: Remodeling and altered ventricular geometry have been described in adults born preterm. Although they seem to have an adverse cardiac phenotype, the impact of various degrees of prematurity on cardiac development has been scarcely reported. In this study, we evaluated the impact of gestational age (GA) at birth on cardiac dimensions and function at near-term age among extremely preterm infants. METHODS: This is a retrospective single-center cohort study of infants born at <29 weeks of GA between 2015 and 2019. Infants with available clinically acquired echocardiography between 34 and 43 weeks were included. Two groups were investigated: those born <26 weeks and those born ≥26 weeks. All measurements were done by an expert masked to clinical data using the raw images. The primary outcome was measurements of cardiac dimensions and function based on GA group. Secondary outcomes were the association between cardiac dimensions and postnatal steroid exposure and with increments of GA at birth. RESULTS: A total of 205 infants were included (<26 weeks, n = 102; ≥26 weeks, n = 103). At time of echocardiography, weight (2.4 ± 0.5 vs 2.5 ± 0.5 kg, P = .86) and age (37.2 ± 1.6 vs 37.1 ± 1.9 weeks, P = .74) were similar between groups. There was no difference in metrics of right-sided dimensions and function. However, left-sided dimensions were decreased in infants born <26 weeks, including systolic left ventricle (LV) diameter (1.06 ± 0.20 cm vs 1.12 ± 0.18 cm, P = .02), diastolic LV length (2.85 ± 0.37 vs 3.02 ± 0.57 cm, P = .02), and estimated LV end-diastolic volume (5.36 ± 1.69 vs 6.01 ± 1.79 mL, P = .02). CONCLUSIONS: In our cohort of very immature infants, birth at the extreme of prematurity was associated with smaller left cardiac dimensions around 36 weeks of corrected age. Future longitudinal prospective studies should evaluate further the impact of prematurity on LV development and performance and their long-term clinical impact.

Newborns with a Congenital Heart Defect and Diastolic Steal Have an Altered Cerebral Arterial Doppler Profile.

OBJECTIVES: To compare trends in the anterior cerebral artery (ACA) Doppler markers of vascular flow for neonates with a congenital heart defect (CHD) with and without diastolic systemic steal during the first 7 days of life. METHODS: Prospective study recruiting newborns (≥35 weeks of gestation) with a CHD. Doppler ultrasound and echocardiography were performed daily from day 1 to 7. The cohort was divided into the presence/absence of holo-diastolic retrograde flow in the postductal aorta ("retrograde") on the last-available echocardiogram. Data extractors were masked to retrograde status. Mixed effect models (random slope/intercept) were constructed using RStudio. RESULTS: We enrolled 38 neonates with CHD. Retrograde aortic flow was present on the last echocardiogram in 23 (61%). Peak systolic velocity and mean velocity increased significantly over time, independent of retrograde status. However, having a "retrograde" flow status conferred a significant decrease over time of their ACA-end-diastolic velocity (ß = -5.75 cm/s, 95% CI -8.38 to -3.12, P < .001, when compared with the nonretrograde group), and a significant increase in the ACA resistive (ß = 0.16, 95% CI 0.10-0.22, P < .001) and pulsatility (ß = 0.49, 95% CI 0.28-0.69, P < .001) indexes. No subject presented retrograde diastolic flow in the ACA. CONCLUSIONS: In neonates with CHD in the first week of life, infants with echocardiographic signs of systemic diastolic steal within the pulmonary circulation have Doppler signs of cerebrovascular steal in the ACA.

The biventricular contribution to chronic pulmonary hypertension of the extremely premature infant.

OBJECTIVE: Evaluate factors associated with significant pulmonary hypertension [PH] (≥2/3 systemic) and its impact on ventricular function at 36 weeks postmenstrual age (PMA). STUDY DESIGN: Retrospective cohort of infants born at <29 weeks who survived to their echocardiography screening for PH at 36 weeks PMA. Masked experts extracted conventional and speckle-tracking echocardiography [STE] data. RESULTS: Of 387 infants, 222 were included and 24 (11%) categorized as significant PH. Significant PH was associated with a decrease in tricuspid annular plane systolic excursion (0.79 vs 0.87 cm, p = 0.03), right peak longitudinal strain [pLS] by STE (-19.6 vs -23.1%, p = 0.003) and left pLS (-25.0 vs -22.7%, p = 0.02). The association between biventricular altered function by STE and significant PH persisted after adjustment for potential confounders - LV-pLS (p = 0.007) and RV-pLS (p = 0.01). CONCLUSION: Our findings are suggestive that premature newborns with significant PH at 36 weeks PMA have a biventricular cardiac involvement to their pathophysiology.

Integrated breast massage versus traditional breast massage for treatment of plugged milk duct in lactating women: a randomized controlled trial.

BACKGROUND: Plugged milk duct during lactation is a common problem in breastfeeding. Traditional breast massage (TBM) has been performed in Thailand with reasonable outcomes, but several follow-up sessions are often required. A new massage technique, the integrated breast massage (IBM), was subsequently developed. This study aimed to compare resolution time, reduction in mass size, and pain score after breast massage between the IBM and TBM techniques. METHODS: This randomized controlled trial was conducted at the Lactation Clinic of the Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand during February 2019-July 2020. Women presenting with acute plugged milk duct were enrolled and randomly allocated to the IBM or TBM/control groups. Mass size in square centimeters (cm2) was calculated by multiplying the perpendicular axes of the mass. Pain score was self-scored by participants using a numerical rating scale. Median time (95% confidence interval [CI]) to resolution of plugged milk duct was derived using Kaplan-Meier survival analysis. Intention-to-treat analysis was performed. RESULTS: Eighty-four women (42 per group) were included. All enrolled study participants completed the study and were included in the final analysis. Twenty-six (61.9%) and 25 (59.5%) participants from IBM and TBM, respectively, had mass diameter > 5 cm. The median (interquartile range [IQR]) mass size was 30 (20-48) and 20 (12-14) cm2 in IBM and TBM (p = 0.05), respectively. The median (95% CI) time to resolution of plugged duct was 0 (not available) and 1 (0.47-1.53) day in IBM and TBM, respectively (p < 0.01). After the first breast massage, the median (IQR) size of mass reduction was 30 (20-48) and 10 (10-26) cm2 in IBM and TBM, respectively (p = 0.01). The median (IQR) reduction in pain score was 8 (7-8) and 6 (4-7) in IBM and TBM, respectively (p = 0.01). No participants developed skin bruising or hematoma after breast massage. CONCLUSIONS: The IBM technique resolved plugged milk duct significantly faster, with significantly less pain, and with significantly greater reduction in mass size after the first massage compared to TBM. TRIAL REGISTRATION: Retrospectively registered in the Thai Clinical Trials Registry on 25 September 2019 ( TCTR20190925001 ).

Early Echocardiography Predicts Intervention Need in Antenatal Suspicion of Coarctation of the Aorta.

Background: Coarctation of the aorta (CoA) is challenging to diagnose in early postnatal life. We aimed to describe the resource utilization and predictors for the need of intervention in an antenatal suspicion of CoA. Methods: A retrospective study of infants with an antenatal suspicion of CoA born at ≥37 weeks was performed. Those not requiring intervention (normal) were compared with those who required cardiac surgery (CoA). Strain was measured using speckle-tracking echocardiography. Results: A total of 51 newborns were included; 40 (78%) were considered normal and 11 (22%) underwent intervention. Echocardiography occurred within the first day of life for both groups. Right ventricular (RV) predominance was present in the CoA group, as demonstrated by the left ventricular (LV) end-systolic eccentricity index (1.60 [0.28] vs 2.16 [0.45]; P < 0.001) and by a larger RV end-diastolic area (EDA) in apical 4-chamber (A4C) relative to LV-EDA-with a ratio of 1.56 [0.23] vs 1.02 [0.2]; P < 0.001. An RV/LV EDA ratio in A4C ≥1.3 had a high probability for CoA (area under the curve = 0.97). Newborns with CoA had a lower RV deformation (peak systolic strain rate: -0.98 [0.17] vs -0.83 [0.2]; P = 0.02). Intraclass correlation coefficient for the EDA ratio revealed a good inter-rater agreement (0.76; 95% confidence interval: 0.55-0.87). Analysis with rater #2 revealed that the EDA ratio ≥1.3 predicted 100% of CoA. Conclusions: The majority of those with an antenatal suspicion of CoA did not require intervention but were high consumers of resources. Within the first day of life, the ventricular EDA ratio in A4C may help predicting those with true CoA requiring intervention.

Contexte: La coarctation de l'aorte (CoA) est difficile à diagnostiquer au début de la vie postnatale. Nous avons voulu décrire l'utilisation de ressources et les facteurs prédictifs à prendre en compte pour déterminer la nécessité d'une intervention en cas de suspicion prénatale de CoA. Méthodologie: Une étude rétrospective portant sur des nourrissons nés à ≥ 37 semaines chez qui il y avait une suspicion prénatale de CoA a été réalisée. Ceux chez qui aucune intervention n'a été nécessaire (groupe de sujets sans anomalie) ont été comparés à ceux chez qui une intervention chirurgicale cardiaque a été nécessaire (groupe de sujets présentant une CoA). L'échocardiographie de suivi des marqueurs acoustiques (speckle-tracking echocardiography) a servi à mesurer la déformation. Résultats: Au total, 51 nouveau-nés ont été inclus; 40 (78 %) ne présentant aucune anomalie selon les évaluateurs, et 11 (22 %) ayant subi une intervention. L'échocardiographie a été réalisée au cours du premier jour de vie dans les deux groupes. Une prédominance ventriculaire droite existait chez les sujets présentant une CoA, comme l'ont démontré l'indice d'excentricité ventriculaire gauche télésystolique (1,60 [0,28] vs 2,16 [0,45]; P < 0,001) et la plus grande surface télédiastolique du ventricule droit (STDVD) en vue apicale 4 cavités (A4C) par rapport à la surface télédiastolique du ventricule gauche (STDVG) ­ le rapport étant de 1,56 [0,23] vs 1,02 [0,2]; P < 0,001. Un rapport STDVD/STDVG en A4C ≥ 1,3 correspondait à une forte probabilité de CoA (aire sous la courbe = 0,97). La déformation ventriculaire droite était moindre chez les nouveau-nés présentant une CoA (taux de déformation systolique maximal : −0,98 [0,17] vs −0,83 [0,2]; P = 0,02). Le coefficient de corrélation intraclasse pour le rapport des surfaces télédiastoliques a révélé une bonne concordance interévaluateurs (0,76; intervalle de confiance à 95 % : 0,55-0,87). L'analyse de l'évaluateur no 2 a révélé qu'un rapport des surfaces télédiastoliques ≥ 1,3 avait une valeur prédictive de 100 % au regard de la CoA. Conclusions: Dans la majorité des cas où il y avait suspicion prénatale de CoA, aucune intervention n'a été nécessaire, mais les ressources médicales mobilisées étaient importantes. Dans ce contexte, le calcul du rapport des surfaces télédiastoliques ventriculaires en A4C au cours du premier jour de vie peut aider à prévoir les cas où une véritable CoA nécessitera une intervention.

Natural evolution of the patent ductus arteriosus in the extremely premature newborn and respiratory outcomes.

OBJECTIVE: Evaluate spontaneous closure of the patent ductus arteriosus (PDA) in extremely preterm infants and their respiratory outcomes, especially at <26 weeks gestational age (GA). STUDY DESIGN: Retrospective study in <29 weeks, admitted within 24 h after birth (Feb 2015 and Dec 2019). Infants without any intervention to promote ductal closure, ≥1 echocardiography, and alive at discharge were included. RESULTS: Two hundred and fourteen infants (average GA 26.3 ± 1.5 weeks) were included; 84 (39%) <26 weeks. PDA closed spontaneously in 194 (91%); 76/84 (90%) for infants <26 weeks. PDA closure was ascertained on an echocardiography performed at a median age of 36.4 [34.4-40.1] weeks. Rate of moderate-to-severe bronchopulmonary dysplasia decreased throughout the study period (OR for year of birth: 0.70 [95% CI: 0.57-0.87], p = 0.001). CONCLUSION: Majority of extremely preterm infants, including <26 weeks, had spontaneous closure of the ductus before term corrected age. There was a concomitant improvement of respiratory outcomes.

Accuracy of transcutaneous bilirubin measured by the BiliCare device in late preterm and term neonates.

OBJECTIVE: The objective of this study is to explore the accuracy and performance of a new transcutaneous bilirubinometer (TCB) for the screening of jaundice in late preterm and term infants. METHODS: A cross-sectional study was conducted. TCB measurements were performed using the BiliCare(TM) bilirubinometer. Paired TCB and serum bilirubin (SB) measurements were analysed. RESULTS: One hundred and fourteen paired samples were collected from 93 healthy late preterm and term infants. Bilirubin measurements were done at median (interquartile range) of 50.5 (34, 72) hours. The mean (SD) difference between the TCB and SB was 1.87 (1.98) mg/dL. A TCB cut-off level at 8.0 mg/dL provides a sensitivity of 97.3% with a negative predictive value (NPV) of 87.5% to detect a SB level of at least 8.0 mg/dL. For SB levels of at least 10.0 mg/dL, a TCB cut-off at 9.0 mg/dL shows a sensitivity of 97.5%; NPV 95.4%. For a SB level of at least 13.0 mg/dL, a TCB cut-off at 12 or 13 mg/dL had a sensitivity of 92.9% and NPV of 98.7%. CONCLUSION: The BiliCare(TM) demonstrated good performance with positive bias for the screening of jaundice in healthy late preterm or term infants. However, if adopted, proper cut-off levels should be chosen because of sub-optimal device precision.